Sleep Study Address: 1087 TOWN CENTER DRIVE, ORANGE CITY, FL 32763
(386) 917-0333 OR (386) 218-3862

Patient Instruction Sheet – Sleep Study

Your health care provider , has requested your attendance for an overnight Sleep Study at ADVANCED SLEEP DISORDER CENTER, located at 1087 Town Center Drive, Orange City, FL,, on at 8:30 P.M.

**Please do not arrive before your appointment time unless previously arranged**
Please take the time to read the following instructions carefully. Complete the enclosed forms and bring them with you along with a list of all your medications on your appointment date.
Below are a few things that will better prepare you for your night with us:
  1. Try to avoid caffeine (coffee, tea, cola, chocolate, etc.) after 5:00 PM and eat dinner to arrival.
  2. Try not to nap on the day of your Sleep Study.
  3. Pajamas, nightgown or shorts and a T-shirt are acceptable sleeping attire. Try to avoid satin, nylon and silk fabrics as well as pajamas with elastic around the ankles. Sleeping in undergarments only is not allowed. Please be advised that members of the opposite sex may be scheduled for the same night of your study.Please dress appropriately.
  4. Personal toiletries such as toothpaste, toothbrush, etc. should be included in your overnight bag.
  5. Wash and dry your hair on the day of your sleep test prior to coming to the lab. Please leave hair free of any product. No hairpieces of any type.
  6. Do not wear make-up and limit application of moisturizer unless it is prescribed.
  7. Remove nail polish and/or artificial nails from at least two fingers.
  8. Try to get a normal night’s sleep before the test. Unless instructed otherwise by your doctor, continue to take your regular medications.
  9. If you are having CPAP study, it is NOT necessary to bring yours. You may, however, bring your CPAP mask or nasal pillows.
  10. Testing usually ends between 5:00 AM and 5:30 AM. Please make arrangements for transportation pickup between 5:45 AM and 6:00 AM if you do not drive yourself.
  11. Due to testing requirements, no one is permitted to sleep in the bed with the patient. Family and friends are asked to make other arrangements. Should you have any special needs, please contact us prior to your Sleep Study so that we can make any necessary accommodations or arrangements.
  12. Feel free to bring a book or a favorite pillow. Please note each room has a television should you wish to watch TV prior to going to sleep.
  13. Please allow 2 – 3 weeks for sleep results to be finalized.
ADVANCED SLEEP DISORDER CENTER is staffed by highly trained healthcare professional who are committed to making your experience as comfortable as possible. Please be advised that your technician may be of the opposite sex. If you have any questions, concerns or special requests, please contact us at (386) 218-3862 and a representative will gladly assist you.
Please note: Due to the in-depth study process and appointment limitations, all No Show appointments are subject to a $250 charge. If you are unable to keep your appointment, please call us to reschedule within 48 hours of your arrival time in order to avoid this charge. Thank you.


PATIENT QUESTIONAIRE



LAST FIRST M.I. SOCIAL SECURITY NUMBER



MALEFEMALE
Number(s) we may use to contact and/or leave messages regarding your appointments, results and recommendations:








Please list all medications you are currently taking, including any sedative, tranquilizers, sleeping pills and muscle relaxants, even if used infrequently.
 
 
 
 
 
 
I hereby authorize my insurance benefits to be paid directly to the Advanced Sleep Disorder Center. I hereby authorize release of pertinent medical information to insurance carriers, medical equipment companies and / or other physicians for the continuation of health care. I understand that if my appointment is not cancelled within the guidelines of our confirmation policy, I will be responsible for a $250 cancellation fee.
 


 
It is important for you to be as accurate as possible in answering the following questions. The purpose of this questionnaire is to get a total picture of your background and the nature of your present problem. Please complete these questions as thoroughly as you can. You may find it useful to use your bed partner’s observations or comments
 
1. Please describe your main sleep problem, in your own words, including when and how this began and what
treatment you have received for this in the past.
2. How do you describe your sleep problem? Check all that apply to you
Difficulty falling asleepWake up during the nightExcessive daytime sleepinessDifficulty awakening
3. Has it been a continuous or an intermittent problem?
Almost every nightFor periods of at least one weekIrregularlyOther
4. How long has this problem bothered you?
Longer than two yearsOne or two yearsSeveral monthsWithin the last three monthsWithin the last month
5. Do any other members of your family have sleep problems?
YesNo



6. What treatment have you received for your sleep problem?
7. How many hours of sleep do you usually get per night?
8. At what time do you go to bed?
WEEKDAYS
WEEKENDS
9. At what time do you usually wake up?
WEEKDAYS
WEEKENDS
10. How long does it take for you to fall asleep?
11. If you awakened during the night (after you first fall asleep), which part(s) of your sleep period is it?
Soon after falling asleepMiddle of the nightEarly morning
12. How many times do you typically wake up at night?
13. If you wake up, in average, how long do you stay awake?
Epworth Sleepiness Scale
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently;
imagine if you were given the opportunity. Use the following scale to choose the most appropriate number for
each situation.
 
0 = would never doze
1 = slight chance of dozing
2 = moderate chance of dozing
3 = high chance of dozing
 
SITUATION: CHANCE OF DOZING
Sitting and reading
0123
Sitting and talking to someone
0123
Lying down to rest in the afternoon when circumstances permit
0123
As a passenger on a care for an hour without a break
0123
Sitting, inactive in a public place (e.g. a theater or meeting)
0123
Watching TV
0123
Sitting quietly after lunch (without alcohol)
0123
In the car while stopped for a few minutes in the traffic
0123
Add the above values to determine your score
 
Please rate how often you:
Never Rarely Sometimes Frequently Constantly
Awaken from sleep short of breath NeverRarelySometimesFrequentlyConstantly
Awaken at night with heartburn, belching or cough or wheezing NeverRarelySometimesFrequentlyConstantly
Snore NeverRarelySometimesFrequentlyConstantly
Having breathing problems during the night NeverRarelySometimesFrequentlyConstantly
Suddenly wake up gasping for breath during the night NeverRarelySometimesFrequentlyConstantly
Snore loudly enough that others complain NeverRarelySometimesFrequentlyConstantly
Feel unable to move (paralyzed) when waking up or falling asleep NeverRarelySometimesFrequentlyConstantly
Fall asleep during the day NeverRarelySometimesFrequentlyConstantly
Fall asleep involuntarily NeverRarelySometimesFrequentlyConstantly
Fall asleep while driving NeverRarelySometimesFrequentlyConstantly
Fall asleep when laughing or crying NeverRarelySometimesFrequentlyConstantly
Remember your dreams NeverRarelySometimesFrequentlyConstantly
Have trouble with work or school because of sleepiness NeverRarelySometimesFrequentlyConstantly
Notice your heart pounding or beating irregularly during the night NeverRarelySometimesFrequentlyConstantly
Experience vivid dreams like scenes upon waking up or falling asleep NeverRarelySometimesFrequentlyConstantly
Have nightmares NeverRarelySometimesFrequentlyConstantly
Experience any type of leg pain during the night NeverRarelySometimesFrequentlyConstantly
Kick during the night NeverRarelySometimesFrequentlyConstantly
Grind teeth during sleep NeverRarelySometimesFrequentlyConstantly
Notice that part of your body jerk during the night NeverRarelySometimesFrequentlyConstantly
Have morning jaw pain NeverRarelySometimesFrequentlyConstantly
Experience crawling and aching feelings in your legs NeverRarelySometimesFrequentlyConstantly
 
Have you ever been diagnosed with any of the following or are you being treated or followed by a physician for:
  Yes No If yes, please explain
Heart Disease YesNo
Heart Failure YesNo
Angina YesNo
Hyper Tension YesNo
Previous Stroke YesNo
Diabetes Mellitus YesNo
Anxiety YesNo
Bronchitis YesNo
Bipolar Disorder YesNo
Fibromyalgiar YesNo
Obesity YesNo
Bronchiectasis YesNo
Depression YesNo
Other YesNo
  Yes No If yes, please explain
Sinusitis YesNo
Poliomyelitis YesNo
Cancer YesNo
Arrhythmia YesNo
Arthritis YesNo
Asthma YesNo
Emphysema YesNo
Pneumonia YesNo
Tuberculosis YesNo
Seizures YesNo
Pulmonary Fibrosis YesNo
Pneumothorax YesNo
Pulmonary Emboli YesNo
 
Answer the question below ONLY if you have/had CPAP or BIPAP ordered.
Are you currently using a CPAP or BiPAP machine? YesNo
Are you currently using supplemental oxygen? YesNo
If yes, who is your current Home Healthcare Company?
Please indicate the current pressure of your CPAP / BiPAP:

ABOUT US

When it comes to breathing disorders, our physicians and staff at Pulmonary Practice Associates understand how important it is for you to choose a qualified physician who will provide the best care possible to get you back to living a healthy and comfortable life.


1075 Town Center Dr, Orange City, FL 32763
Phone Number: (386) 917-0333
Fax Number: (386) 917-0335

749 Stirling Center Place, Lake Mary, FL 32746
Phone Number: (407) 321-8230
Fax Number: (407) 321-0388

8400 Red Bug Lake Road, Suite 2010, Oviedo, FL, 32765
Phone Number: (407) 321-8230
Fax Number: (407) 321-0388

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